- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.22 / $23.44 / $120.23
| Professional | | $16.22 | $23.44 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.20 / $23.99 / $43.65
| Professional | | $18.20 | $23.99 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.62 / $35.48 / $41.69
| Professional | | $31.62 | $35.48 | $41.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.62 / $21.88 / $25.70
| Professional | | $18.62 | $21.88 | $25.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.20 / $25.12 / $74.13
| Professional | | $18.20 | $25.12 | $74.13 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.50 / $31.62 / $56.23
| Professional | | $19.50 | $31.62 | $56.23 |